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Executive Summary

2009 Comparative Database Report

In response to requests from hospitals interested in comparing their results to other hospitals on the Hospital Survey on Patient Safety Culture (hospital survey), the Agency for Healthcare Research and Quality (AHRQ) established the Hospital Survey on Patient Safety CultureComparative Database. The first comparative database report was released in 2007. It included data from 382 U.S. hospitals that administered the AHRQ patient safety culture survey to 108,621 hospital staff and voluntarily submitted their data for inclusion in this new database. The second comparative database report was released in 2008. It included data from 519 hospitals that administered the survey to 160,176 hospital staff.

The Hospital Survey on Patient Safety Culture 2009 Comparative Database Report is an update of the 2008 report. The 2009 report includes more data, reporting results from 622 hospitals and 196,462 hospital staff respondents. In addition, the 2009 report includes a chapter on trending that presents results showing change over time for 204 hospitals that administered the survey and submitted data more than once.

Hospitals do not necessarily administer the hospital patient safety culture survey every year. They may administer it on an 18-month, 24-month, or other cycle. Therefore, the comparative database is a "rolling" indicator. It retains data from prior years when a hospital does not have new data to submit, replaces older data with more recent data when available, and adds data from hospitals submitting for the first time. The comparative database report will be produced yearly through at least 2012.

This comparative database report was developed as a tool for the following purposes:

Comparison. To allow hospitals to compare their patient safety culture survey results to other hospitals.

Assessment and learning. To provide data to hospitals to facilitate internal assessment and learning in the patient safety improvement process.

Supplemental information. To provide supplemental information to help hospitals identify their strengths and areas with potential for improvement in patient safety culture.

Trending. To provide data that describe changes in patient safety culture over time.

Development of the Survey

The hospital survey was pilot tested and revised and then released in November 2004. It was designed to assess hospital staff opinions about patient safety issues, medical error, and event reporting. The survey includes 42 items that measure 12 areas or composites of patient safety culture, including:

Communication openness

Feedback and communication about error

Frequency of events reported

Handoffs and transitions

Management support for patient safety

Nonpunitive response to error

Organizational learning-continuous improvement

Overall perceptions of patient safety

Staffing

Supervisor/manager expectations and actions promoting safety

Teamwork across units

Teamwork within units

The survey also includes two questions that ask respondents to provide an overall grade on patient safety for their work area/unit and to indicate the number of events they have reported over the past 12 months.

2009 Database Hospitals

The hospitals in the 2009 database fall into three categories:

395 hospitals from the previous database report that are still included in the 2009 report, of which:

314 hospitals submitted data one time; and

81 hospitals submitted data twice; older data were replaced by data from their readministration, so the database reflects their most recent survey data.

227 hospitals that submitted data for the 2009 report, of which:

104 hospitals submitted data for the first time; and

123 hospitals submitted data from a readministration of the survey; older data from these hospitals were replaced by data from their readministration, so the database reflects their most recent survey data.

Survey Administration Statistics

The average hospital response rate was 52 percent, with an average of 316 completed surveys per hospital.

Most respondents (77 percent) indicated that they had direct interaction with patients.

Areas of Strength for Most Hospitals

Two areas emerged as areas of strength. Results are expressed in terms of percent positive response. Percent positive is the percentage of positive responses (e.g., Agree, Strongly agree) to positively worded items (e.g., "People support one another in this unit") or negative response (e.g., Disagree) to negatively worded items (e.g., "We have safety problems in this unit").

Teamwork Within Units—This is an area of strength for most hospitals, with the highest average percent positive response (79 percent). Teamwork is defined as the extent to which staff support one another, treat each other with respect, and work together as a team. The survey item with the highest average percent positive response (86 percent) was: "When a lot of work needs to be done quickly, we work together as a team to get the work done."

Patient Safety Grade—On average, most respondents within hospitals (73 percent) gave their work area or unit a grade of either "A-Excellent" (25 percent) or "B-Very Good" (48 percent) on patient safety. However, the grades varied widely, from at least one hospital where none of the respondents (0 percent) gave their unit a patient safety grade of "A-Excellent," to a hospital where 63 percent did.

Areas With Potential for Improvement for Most Hospitals

Three areas showed potential for improvement.

Nonpunitive Response to Error—This is an area with potential for improvement for most hospitals. Nonpunitive response to error is defined as the extent to which staff feel that their mistakes and event reports are not held against them and that mistakes are not kept in their personnel file. This area was one of the two patient safety culture composites with the lowest average percent positive response (44 percent). The survey item with the lowest average percent positive response was: "Staff worry that mistakes they make are kept in their personnel file" (an average of only 35 percent).

Handoffs and Transitions—The extent to which important patient care information is transferred across hospital units and during shift changes was the other patient safety culture composite with the lowest average percent positive response (44 percent). The survey item with the lowest average percent positive response was: "Things 'fall between the cracks' when transferring patients from one unit to another" (an average of only 41 percent).

Number of Events Reported—On average, most respondents within hospitals (52 percent) reported no events in their hospital over the past 12 months. It is likely events were underreported. Event reporting and was identified as an area for improvement for most hospitals because potential patient safety problems may not be recognized or identified and therefore may not be addressed. However, responses varied widely in the number of events reported. Respondents ranged from one hospital where 96 percent of respondents had not reported a single event over the past 12 months, to one where only 5 percent had not reported an event.

Overall Results by Hospital Characteristics

Results on the survey's patient safety culture composites and items by hospital characteristics (bed size, teaching status, ownership and control, geographic region) are highlighted. A 5 percent difference in percent positive scores was used as a rule of thumb to identify meaningful differences in scores.

Bed Size

Smaller hospitals (49 beds or fewer) had the highest average percent positive response on all 12 patient safety culture composites.

The largest difference by bed size was on Handoffs and Transitions, where the smallest hospitals (6-24 beds) scored 22 percent higher than large hospitals (400-499 beds) (55 percent positive compared with 33 percent positive).

Large hospitals (400-499 beds) scored lowest on the percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very good" (64 percent for 400-499 beds compared with 78 percent for 25-49 beds).

There were no noticeable differences on number of events reported based on bed size (all differences were 3 percent or less).

Teaching Status and Ownership and Control

Non-teaching hospitals had the highest average percent positive response on Teamwork Across Units and Handoffs and Transitions.

Government-owned hospitals were more positive than non-government on Handoffs and Transitions (6 percent more positive) and Staffing (5 percent more positive).

There were no noticeable differences on patient safety grade or number of events reported based on teaching status or ownership and control (all differences were 3 percent or less).

East South Central hospitals had the highest average percent positive response across the 12 patient safety culture composites; Pacific hospitals had the lowest.

The largest difference by region was on Staffing and Handoffs and Transitions where West North Central hospitals were 10 percent more positive than Mid Atlantic/New England hospitals (for Staffing) and Pacific hospitals (for Handoffs and Transitions).

West South Central hospitals scored highest on the percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very Good" (77 percent).

Pacific hospitals had the highest percentage of respondents who reported one or more events in the past year (53 percent); the lowest percentage of respondents reporting events was in the West South Central region (40 percent).

*Note: States are categorized into AHA-defined regions as follows:

Mid Atlantic/New England: NJ, NY, PA/CT, ME, MA, NH, RI, VT

West North Central: IA, KS, MN, MO, ND, NE, SD

South Atlantic: DE, DC, FL, GA, MD, NC, SC, VA, WV

West South Central: AR, LA, OK, TX

East North Central: IN, IL, MI, OH, WI

Mountain: AZ, CO, ID, MT, NM, NV, UT,WY

East South Central: AL, KY, MS, TN

Pacific: AK, CA, HI, OR, WA

Overall Results by Respondent Characteristics

Results on the survey's patient safety culture composites and items by respondent characteristics (work area/unit, staff position, interaction with patients) are highlighted. A 5 percent difference in percent positive scores was used as a rule of thumb to identify meaningful differences in scores.

Work Area/Unit

Respondents in Rehabilitation had the highest average percent positive response on 8 of the 12 patient safety culture composites.

The largest difference by work area/unit was on Nonpunitive Response to Error (22 percent). On this composite, Rehabilitation was 59 percent positive and Emergency was 37 percent positive.

Rehabilitation had the highest percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very Good" (81 percent); Emergency and Medicine had the lowest percentage (62 percent).

ICU (any type) had the highest percentage of respondents reporting one or more events in the past year (66 percent); Anesthesiology had the lowest percentage of respondents reporting events (43 percent).

Staff Position

Respondents in Administration/Management had the highest average positive response on 11 of the 12 patient safety culture composites.

The largest difference (26 percent) by staff position was on Nonpunitive Response to Error; Administration/Management was 62 percent positive and Patient Care Assistants Aides/Care Partners were 36 percent positive.

Administration/Management had the highest percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very Good" (82 percent); Registered Nurse/LVN/LPN had the lowest percentage (66 percent).

Pharmacists had the highest percentage of respondents reporting one or more events in the past year (75 percent); Unit Assistants/Clerks/Secretaries had the lowest percentage reporting events (22 percent).

Interaction With Patients

Respondents with direct patient interaction were 7 percent more positive on Handoffs and Transitions compared with those without direct patient interaction (45 percent positive compared with 38 percent positive).

Respondents without direct patient interaction were 7 percent more positive about Management Support for Patient Safety than those with direct patient interaction (76 percent compared with 69 percent positive).

Respondents without direct patient interaction had the highest percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very Good" (77 percent) compared with those with direct patient interaction (72 percent).

More respondents with direct patient interaction reported one or more events in the past year (53 percent) than respondents without direct patient interaction (32 percent).

Trending: Comparing Results Over Time

Results regarding changes over time on the patient safety culture composites and items for the 204 hospitals (of the 622 total database hospitals) that administered the survey and submitted data more than once are highlighted. When comparing results over time, a 5 percent difference in percent positive scores between the previous and most recent survey administrations was used as a rule of thumb to identify meaningful changes in scores over time.

For the 204 hospitals with trending data, the average length of time between previous and most recent survey administrations was 16 months (range: 7 months to 35 months).

The average change in percent positive scores between administrations on the patient safety culture composites was a slight increase of 2 percent (ranging from 1 to 3 percent change).

In 37 percent of trending hospitals, an increased was seen of 5 percent or more on Overall Perceptions of Patient Safety.

In 22 percent of hospitals, a decrease was seen in percent positive scores by 5 percent or more on Organizational Learning-Continuous Improvement.

There were no noticeable differences in the percentage of respondents who gave their work area/unit a patient safety grade of "A-Excellent" and "B-Very Good" (average percentage increased by 4 percent).

There were no noticeable differences in the number of events reported by respondents in the past 12 months (the average percentage of respondents reporting one or more events increased by only 2 percent).

Trending Results by Hospital Characteristics

Quantitative and qualitative data on changes in patient safety culture over time are highlighted. Quantitative data include questionnaire data on actions taken by the trending hospitals to improve their patient safety culture, as well as correlations between improvement efforts and changes in hospital survey scores. Qualitative data consist of findings from nine interviews conducted with staff of trending hospitals, who provided potential explanations for increases and decreases in their hospitals' hospital survey scores.

Results for the 204 trending hospitals regarding changes over time on the patient safety culture composites and items by hospital characteristics are highlighted. When comparing results over time, a 5 percent difference in percent positive scores between the previous and most recent survey administrations was used as a rule of thumb to identify meaningful changes in scores.

Trending: Bed Size

Hospitals with 100-299 beds had the largest increases in percent positive response over time on 10 of the 12 patient safety culture composites (average increase across the 10 composites was 5 percent).

Hospitals with 200-299 beds had the greatest average change across the 12 patient safety culture composites (average 5 percent change).

The largest increase over time was for medium-large hospitals (200-299 beds) on Teamwork Within Units and Organizational Learning—Continuous Improvement, both increasing 8 percent from the previous administration.

The largest decrease over time was for large hospitals (500 or more beds) on the Overall Perceptions of Patient Safety, decreasing 6 percent from the previous administration.

Small hospitals (6-24 beds) had the highest increase in percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very good" (a 7 percent increase, from 71 percent in the previous administration to 78 percent in the most recent administration).

Small hospitals (6-24 beds) also had the highest increase in percentage of respondents reporting one or more events in the past year (a 6 percent increase, from 41 percent to 47 percent).

Trending: Teaching Status and Ownership and Control

There were no noticeable differences or changes across the patient safety culture composites for teaching versus non-teaching hospitals or government-owned versus nongovernment hospitals (all changes and differences were 4 percent or less).

Non-teaching hospitals had a greater increase than teaching hospitals in the percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very Good" (a 5 percent increase, from 69 percent to 74 percent).

Government-owned hospitals had a greater increase than nongovernment hospitals in the percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very Good" (a 6 percent increase, from 69 percent to 75 percent).

There were no noticeable differences or changes in the percentage of respondents who reported one or more events in the past year based on teaching status.

Government-owned hospitals had a greater increase than nongovernment hospitals in the percentage of respondents who reported one or more events in the past year (a 5 percent increase, from 42 percent to 47 percent).

Trending Results by Respondent Characteristics

Results for the 204 trending hospitals regarding changes over time on the patient safety culture composites and items by respondent characteristics are highlighted. When comparing results over time, a 5 percent difference in percent positive scores between the previous and most recent survey administrations was used as a rule of thumb to identify meaningful changes in scores.

Trending: Work Area/Unit

Respondents in Psych/Mental Health had the greatest average change in percent positive response across the 12 patient safety culture composites, with an average change of 5 percent.

Respondents in Obstetrics had the largest increases in positive response over time on 5 of the 12 patient safety culture composites (average increase across the 5 composites was 6 percent).

Respondents in Anesthesiology had the largest decreases in positive response over time on 4 of the 12 patient safety culture composites (average decrease across the 4 composites was 5 percent).

Medicine had the largest average percentage of respondents who increased over time in giving their work area/unit a patient safety grade of "Excellent" or "Very Good" (an 8 percent increase, from 56 percent to 64 percent), followed by ICU (7 percent increase), Surgery (6 percent increase), and Lab (5 percent increase).

Lab had the largest average percentage of respondents who increased over time in their reporting of one or more events in the past year (a 7 percent increase, from 48 percent to 55 percent), followed by Anesthesiology, Radiology, and Rehabilitation (all increasing by 5 percent). The largest decrease in percentage reporting events was in Obstetrics (a 6 percent decrease, from 58 percent to 52 percent)

Trending: Staff Position

Pharmacists had the largest increases in positive response over time on 4 of the 12 patient safety culture composites (average increase across the 4 composites was 6 percent).

Admin/Mgmt, RN/LVN/LPN, and Technicians had the largest average percentage of respondents who increased over time in giving their work area/unit a patient safety grade of "Excellent" or "Very Good" (5 percent increase).

There were no noticeable differences in the percentage of respondents reporting one or more events over time based on staff position (all changes over time were less than 5 percent).

Trending: Interaction With Patients

There were no noticeable composite differences over time based on respondent interaction with patients (all were increases over time of 4 percent or less).

There were no noticeable differences in the percentage of respondents giving their work unit/area a patient safety grade of "Excellent" or "Very Good" or those reporting one or more events over time based on respondent direct patient interaction.

Action Planning for Improvement

The delivery of survey results is not the end point in the survey process, it is just the beginning. Often, the perceived failure of surveys to create lasting change is actually due to faulty or nonexistent action planning or survey followup. Seven steps of action planning are provided to give hospitals guidance on next steps to take to turn their survey results into actual patient safety culture improvement.